Classification of Professor Yasser

• Primary headaches• OR Idiopathic headaches

– THE HEADACHE IS ITSELF THE DISEASE

– NO ORGANIC LESION IN THE BEACKGROUND

– TREAT THE HEADACHE!

••

Classification of headachesProfessor Yasser Metwally

Secondary headachesOR Symptomatic headaches

– THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE

– TREAT THE UNDERLYING DISEASE!

HISTORY AND EXAMINATIONS SHOULD CLARIFY IF

• THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE

• IS THERE ANY URGENCY• IN CASE OF PRIMARY HEADACHE ONLY THE

HEADACHE ATTACKS SHOULD BE TREATED („ATTACK THERAPY”), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY („PREVENTIVE THERAPY, INTERVAL THERAPY”)

HISTORY AND EXAMINATIONS SHOULD CLARIFY IF

THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE IS THERE ANY URGENCYIN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED („ATTACK THERAPY”), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY („PREVENTIVE THERAPY, INTERVAL

SECONDARY, SYMPTOMATIC HEADACHES

• THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE– Hypertension– Sinusitis– Glaucoma– Eye strain– Fever– Cervical spondylosis – Anaemia– Temporal arteriitis – Meningitis, encephalitis– Brain tumor, meningeal carcinomatosis– Haemorrhagic stroke…

SECONDARY, SYMPTOMATIC HEADACHES

THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE

Brain tumor, meningeal carcinomatosis

• Secondary headache disorders

Headache attributed to ...5. head and/or neck trauma6. cranial or cervical vascular disorder7. non-vascular intracranial disorder8. a substance or its withdrawal9. infection

10. disorder of homoeostasis11. disorder of cranium, neck, eyes, ears, nose,

sinuses, teeth, mouth or other facial or cranial structures

12. psychiatric disorder13. cranial neuralgias and central causes of facial

pain

Secondary headache disorders

5. head and/or neck trauma6. cranial or cervical vascular disorder

vascular intracranial disorder8. a substance or its withdrawal

10. disorder of homoeostasis11. disorder of cranium, neck, eyes, ears, nose,

sinuses, teeth, mouth or other facial or cranial

cranial neuralgias and central causes of facial

Primary, idiopathic headaches

• Tension type of headache• Migraine• Cluster headache• Other, rare types of primary

headaches

Primary, idiopathic headaches

Tension type of headache

Other, rare types of primary

Treatment of tension type of headache

• Acute, episodic form:mg ASA, paracetamol, or noraminophenazon

• Indication of prophylactic treatmenttype of headache in at least 14 days per moth

Treatment of tension type of headache

NSAID drugs, 500-1000 mg ASA, paracetamol, or noraminophenazon

Indication of prophylactic treatment: tension type of headache in at least 14 days per moth

Prophylactic treatment of the chronic tension type of headache

• Tricyclic antidepressants• Guidelines:

Start with low dose (10-25 mg) and increase the dose if no beneficial effect after 1

Maximal dose should not be more than 75 mg/day Change to other tricyclic antidepressant only after 6

weeks Ask the patient to use headache diary Use the tricyclic antidepressant for 6 Decrease the dose gradually

Prophylactic treatment of the chronic tension type of headache

Tricyclic antidepressants

25 mg) and increase the dose if no beneficial effect after 1-2 weeksMaximal dose should not be more than 75 mg/dayChange to other tricyclic antidepressant only after 6-8

Ask the patient to use headache diaryUse the tricyclic antidepressant for 6-9 monthsDecrease the dose gradually

First choice of drug: amitryptiline (Teperin tabl, 25 mg)• 1st week: 25 mg in the evening• 2nd week: 50 mg in the evening• 3rd week: 75 mg in the evening continuously• Change to other drug (e.g. clomipramine) if no

beneficial effect within 6 weeks

Prophylactic treatment of the chronic tension type of headache

First choice of drug: amitryptiline (Teperin tabl, 25 mg)

1st week: 25 mg in the evening2nd week: 50 mg in the evening3rd week: 75 mg in the evening continuouslyChange to other drug (e.g. clomipramine) if no beneficial effect within 6 weeks

Prophylactic treatment of the chronic tension type of headache

Common side effects of tricyclic antidepressants

• Anticholinergic side effects:– Dry mouth– Increased pulse rate– Urinary retention (in prostate hyperplasia!!!)– Increased intraocular pressure (glaucoma!!!)

• Sleepiness or hyperactivity• Serotonine syndrome (do not use if the

patient takes SSRI drug)

Common side effects of tricyclic antidepressants

Anticholinergic side effects:

Urinary retention (in prostate hyperplasia!!!)Increased intraocular pressure (glaucoma!!!)

Sleepiness or hyperactivitySerotonine syndrome (do not use if the patient takes SSRI drug)

If the patient does not tolerate the TCA drugs, or cannot be administared because of danger of interaction

• Anxiolytics (e.g.: alprasolam, clonazepam…)• and selective antidepressants (e.g. SSRI)• Change of lifestyle• Psychotherapy, psychological treatments,

biofeedback, behavioral therapy, relaxation methods

If the patient does not tolerate the TCA drugs, or cannot be administared because of danger of interaction

Anxiolytics (e.g.: alprasolam, clonazepam…)and selective antidepressants (e.g. SSRI)

Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation

Migraine: epidemiology• Life-time prevalence 10%• 1% chronic migraine (>15 days/months)• Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1• Mean frequency 1.2/month• Mean duration 24 h (untreated) • 10% always with aura, >30% sometimes with

aura• 30% treated by physicians

Migraine: epidemiologytime prevalence 10%-12%

1% chronic migraine (>15 days/months)Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1Mean frequency 1.2/monthMean duration 24 h (untreated) 10% always with aura, >30% sometimes with

30% treated by physicians

Migraine: pathophysiology

• Genetic disposition, hormonal influence• Activation of brainstem nuclei by trigger factors• Neurovascular inflammation of intracranial

vessels• Impaired antinociception• „Spreading Depression“ as mechanism of aura

Migraine: pathophysiology

, hormonal influenceActivation of brainstem nuclei by trigger factorsNeurovascular inflammation of intracranial

Impaired antinociception„Spreading Depression“ as mechanism of aura

Migraine classification

1.1 migraine without aura1.2 migraine with aura1.3 periodic syndromes in childhood1.4 retinal migraine1.5 migraine complications1.6 probable migraine

Migraine classification

1.1 migraine without aura1.2 migraine with aura1.3 periodic syndromes in childhood

1.5 migraine complications

Migraine• WITHOUT AURA• Typical headache 2/4

– Unilateralsi– Severe– Pulsating– Physical activity

aggravates• Accompanying signs 1/2

– Photophobia and phonophobia

– Nausea, or vomitus

Migraine• WITH AURA +

– VISUAL– SENSORY– MOTOR– SPEECH DISTURBANCE

before migraineous headache• AURA SYMPTOMS

– USUALLY<1/2 HOUR– LESS THAN 1 HOUR

MIGRAINE WITH AURA• DURING AURA:

– VASOCONSTRICTION – HYPOPERFUSION

BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION

CUASE OF THE AURA: SPREADING DEPRESSION. THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADIND DEPRESSION

SPREADING DEPRESSION

MIGRAINE WITH AURA• DURING HEADACHE

– VASODILATION– HYPERPERFUSION

BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION

CUASE OF THE AURA: SPREADING DEPRESSION. THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADIND DEPRESSION

AURA

VASOCONSTRICTION, HYPOPERFUSION

IMPORTANT TO KNOW! MIGRAINE WITH AURA

• IS A RISK FACTOR FOR ISCHAEMIC STROKE– THEREFORE PATIENTS SUFFERING FROM

MIGRAINE WITH AURA• SHOULD NOT SMOKE!!!• SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!

• THE PROPROTION OF PATENT FORAMEN OVALE IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55%!IS ABOUT 25%).

IMPORTANT TO KNOW! MIGRAINE WITH AURA

RISK FACTOR FOR ISCHAEMIC STROKETHEREFORE PATIENTS SUFFERING FROM

SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!

PROPROTION OF PATENT FORAMEN IN PATIENTS WITH MIGRAINE WITH

55%! (IN THE POPULATION

Is there a relationship between aura and patent foramen ovale

• ?• Paradoxic emboli theory is not likely• Shunting of venous blood to the arterial side could be the

reason no breakdown of certain neurotransmitters (5HT) in the lung!

• Comorbidity could be also an explanation.

• However, closure of patent foramen ovale decreases the frequency of migraine attacks.

• BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of migraine with aura!

Is there a relationship between aura and patent foramen ovale

Paradoxic emboli theory is not likelyShunting of venous blood to the arterial side could be the

no breakdown of certain neurotransmitters

Comorbidity could be also an explanation.

However, closure of patent foramen ovale decreases the frequency of migraine attacks.BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of

Treatment of migraine attack

• Try to sleep• Antiemetics• Analgetics• Ergot derivatives• Triptans

Treatment of migraine attack

Ergot derivatives

Treatment of migraine attackI. Antiemetics

• 1. Metoclopramid (Cerucal tabl 10 mg) – 10-20 mg per os– 20 mg rectal– 10 mg parenteral

• 2. Domperidon (Motilium tabl 10 mg)– 10-20 mg per os

Treatment of migraine attackI. Antiemetics

1. Metoclopramid (Cerucal tabl 10 mg)

2. Domperidon (Motilium tabl 10 mg)

Treatment of migraine attackII. Analgetics

• 1. ASA (Aspirin, Colfarit, etc)– 500-1000 mg per os

– 500 mg parenteral (Aspisol i.v.)• 2. Paracetamol (Rubophen, Panadol, etc)

– 500-1000 mg per os• 3. NSAIDs

– Ibuprofen (Ibuprofen, Humaprofen, etc) 400– Diclofenac (Voltaren, Cataflam etc)– Naproxen (Naprosyn, Apranax) 250

Treatment of migraine attackII. Analgetics

2. Paracetamol (Rubophen, Panadol, etc)

Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg per os Diclofenac (Voltaren, Cataflam etc)50 mg per osNaproxen (Naprosyn, Apranax) 250-550 mg per os

• 1. Ergotamin tartarate– 2-4 mg per os, sublinguali or rectal– 1 mg nasal spray

• 2. Dihydrergotamin (Neomigran) nasal spray– no more available

Treatment of migraine attack III. Ergot derivatives

1. Ergotamin tartarate4 mg per os, sublinguali or rectal

2. Dihydrergotamin (Neomigran) nasal spray

Treatment of migraine attack III. Ergot derivatives

• Migpriv:– lizin-acetylsalicilate + metoclopramid

• Quarelin: – aminophenazon+coffein+drotaverin

• Kefalgin – ergotamin tartarate+

atropin+coffein+aminophenazon

Treatment of migraine attack IV. Combinations in Hungary

acetylsalicilate + metoclopramid

aminophenazon+coffein+drotaverin

ergotamin tartarate+ atropin+coffein+aminophenazon

Treatment of migraine attack IV. Combinations in Hungary

Treatment of migraine attack V. Triptans

1. Sumatriptan (Imigran® 6 mg inj, 50 and 100 mg tabl, Imitrex nasal spray, suppGlaxo)

2. Zolmitriptan (Zomig®, Zeneca)

3. Naratriptan (Naramig®, Glaxo)

4. Rizatriptan (Maxalt®, MSD)

5. Eletriptan (Relpax, Pfizer)

6. Frovatriptan (Smith-Kleine Beecham)

7. Avitriptan (Bristol-Myers Squibb)

8. Alniditan (Janssen)

Treatment of migraine attack V. Triptans

50 and supp,

6 mg sc with autoinjector 50-100 mg per os, nasal spray 20 mg

2,5 – 5 mg

2,5 mg

5 – 10 mg per os

20 – 80 mg per os

Kleine Beecham) 2,5 mg per os

75 – 150 mg

2 – 4 mg, nasal spray

The ideal triptan• Effective• Rapid onset• No recurrence• Good consistency• Different applications• Good tolerability• No interactions• Cheap

The ideal triptan

Rapid onsetNo recurrenceGood consistencyDifferent applicationsGood tolerabilityNo interactions

Very severe migraine attack / status migrainosus:

• Triptan (sumatriptan 6 mg s.c.)

• Lysin-ASA 1,000 mg i.v.

• Metamizol 500-1,000 mg i.v.

• Antiemetics i.v.

• Steroids i.v.

Attack treatment in emergency

Very severe migraine attack / status migrainosus:

Attack treatment in emergency

Strategy of treatment of migraine attacks

• Step care accross or within attacks– 1: NSAID– 2: ergot– 3: triptan

• Stratified care– do not go through all the steps, but drug can be

chosen depending on the severity of the attack

Strategy of treatment of migraine attacks

Step care accross or within attacks

do not go through all the steps, but drug can be chosen depending on the severity of the attack

Prophylactic treatment of migraine attacks

• Indication: 2 or more attacks/month At least one long (>4 days) attack/month

• Start of prophyalactic treatment: gradually• Duration of prophylactic treatment:• Stop of prophylactic treatment

within 4 weeks• Use headache diary• INFORM THE PATIENT ABOUT THE

PROPHYLACTIC TREATMENT!!!

Prophylactic treatment of migraine attacks

At least one long (>4 days) attack/month

Start of prophyalactic treatment: graduallyDuration of prophylactic treatment: 2-9 monthsStop of prophylactic treatment: gradually,

INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!!

Aims of prophylactic treatment of migraine

• To decrease the frequency of attacks• To decrease the intensity of the pain• To increase the efficacy of attack therapy

Aims of prophylactic treatment of migraine

To decrease the frequency of attacksTo decrease the intensity of the painTo increase the efficacy of attack therapy

Prophylactic treatment of migraine

• Beta-receptor-blockers (propranolol)• Calcium channel blockers (flunarizine)• Antiepileptics (valproic acid)• Tricyclic antidepressants (amitriptyline)• Topiramate (Topamax)• Serotonin antagonists• NSAID

Prophylactic treatment of migraine

blockers (propranolol)Calcium channel blockers (flunarizine)Antiepileptics (valproic acid)Tricyclic antidepressants (amitriptyline)Topiramate (Topamax)

Beta-receptor-blockers(propranolol 2x20-40 mg)

Calcium channel blockers(flunarizine, 10 mg every evening)Side effects: provokes depression, increases appetite, cause sleepiness

Tricyclic antidepressants(amitryptiline, 10-75 mg every evening)

Antiepileptics(valproic acid, 2x300-500 mg)

Use: hypertension, tachycardiaDo not use: hypotension,

bradicardia,heart conduction disturbances

Do not use: obesity, maior depressionin the history

Use: if tension type of headache ispresent besides migraine

Do not use: see above

Few side effects, butPregnancy should be avoided

Other prophylactic treatment of migraine

• Change of life-style• Regular, not exhausting physical activities• Cognitive behavioral therapy• Regular sleeping• Avoid the precipitating factors• Acuouncture?

Other prophylactic treatment of migraine

Regular, not exhausting physical activitiesCognitive behavioral therapy

Avoid the precipitating factors

Migraine and pregnancy• Migraine without aura in >70% of women less

frequent or absent (prognostic factor: menstrual migraine)

• Significantly more manifestation of migraine with aura

• Acute treatment: paracetamol; NSAIDs in second trimenon

• Triptans not allowed• Prophylaxis: magnesium, metoprolol,

(fluoxetine)

Migraine and pregnancyMigraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual

Significantly more manifestation of migraine

Acute treatment: paracetamol; NSAIDs in

Prophylaxis: magnesium, metoprolol,

Migraine in childhood I

• Prevalence 5%• Sex ratio 1:1 (boys with good prognosis)• Abdominal symptoms often predominant• Semiology of attacks as in adulthood

except shorter duration of attacks• Short sleep very effective

Migraine in childhood I

Sex ratio 1:1 (boys with good prognosis)Abdominal symptoms often predominantSemiology of attacks as in adulthood except shorter duration of attacksShort sleep very effective

Migraine in childhood II

• Acute treatment:–First choice: ibuprofen 10 mg/kg–Second choice: paracetamol 15 mg/kg–Third choice: sumatriptan nasal spray 10

mg

• Prophylaxis:–Flunarizine 5-10 mg–Propranolol 80 mg

Migraine in childhood II

First choice: ibuprofen 10 mg/kgSecond choice: paracetamol 15 mg/kgThird choice: sumatriptan nasal spray 10-20

Treatment of cluster attack• Oxygen:7 liters/min 100% oxigén for 15 minutes

– Effective in 75% of patients within 10 minutes• Sumatiptan 6 mg s.c., 50• Ergot derivatives (lot of side effects)• Anaesthesia of the ipsilateral fossa sphenopalatina)

– 1 ml 4% Xylocain nasal drop– The head is turned back and to the ipsilateral sidein 45 degree

Treatment of cluster attackOxygen:7 liters/min 100% oxigén for 15 minutes

Effective in 75% of patients within 10 minutesSumatiptan 6 mg s.c., 50-100 mg per osErgot derivatives (lot of side effects)Anaesthesia of the ipsilateral fossa sphenopalatina)

1 ml 4% Xylocain nasal dropThe head is turned back and to the ipsilateral side

Prophylactic treatment of the episodic form of cluster headache

• Epizodic form: prednisolon• Treatment:

– 1-5. days 40 mg– 6-10. days daily 30 mg – 10-15. days daily 20 mg – 16-20. days daily 15 mg– 21-25. days daily 10 mg– 26-30. days daily 5 mg– nothing

Prophylactic treatment of the episodic form of cluster headache

Epizodic form: prednisolon

10. days daily 30 mg 15. days daily 20 mg 20. days daily 15 mg25. days daily 10 mg30. days daily 5 mg

• Lithium carbonate • Daily 600-700 mg• Can be decreased after 2 weeks remission• Control of serum level is necessary

(0,4 - 0,8 mmol/l)

Prophylactic treatment of the chronic form of cluster headache

Can be decreased after 2 weeks remissionControl of serum level is necessary

Prophylactic treatment of the chronic form of cluster headache

3. Cluster headache and trigemino-autonomic cephalgias

• Trigemino-autonomic cephalgias (TAC)

–Cluster headache–Paroxysmal hemicrania–SUNCT-syndrome–(Hemicrania continua)

3. Cluster headache and autonomic cephalgias

autonomic cephalgias

Cluster headacheParoxysmal hemicrania

syndrome(Hemicrania continua)

Headache of cervical origin• Lidocain infiltration• NSAID: 50-150 mg indomethacin, 20

piroxicam (Hotemin, Feldene), etc• Surgical methods (CV

vertebrae)• Other methods (physiotherapy, TENS)

Headache of cervical origin

150 mg indomethacin, 20-40 mg piroxicam (Hotemin, Feldene), etcSurgical methods (CV-CVII fusion of

Other methods (physiotherapy, TENS)

Arteriitis temporalis• Arteriitis temporalis (age>50y, We>50 mm/h)• Autoimmune disease, granulomatose inflammation of

branches of ECA– Unilateral headache– Pulsating pain, more severe at night– Larger STA– 1/3 jaw claudication inflammation of internal maxillary artery– Weakness, loss of appetite, low fever, – Danger of thrombosis of ophthalmic or ciliary artery!!!– Amaurosis fugax may precede the blindness– Treatment: steroid – 45-60 mg methylprednisolone

the dose after 1-2 weeks to 10 mg!!! – Diagnosis: STA biopsy. – BUT Start the steroid before results of biopsy!!!– We, pain decrease

Arteriitis temporalisArteriitis temporalis (age>50y, We>50 mm/h)Autoimmune disease, granulomatose inflammation of

Pulsating pain, more severe at night

inflammation of internal maxillary arteryWeakness, loss of appetite, low fever, Danger of thrombosis of ophthalmic or ciliary artery!!!Amaurosis fugax may precede the blindness

60 mg methylprednisolone – decrease 2 weeks to 10 mg!!!

Start the steroid before results of biopsy!!!

Facial pains• Tolosa-Hunt syndrome (ophthalmoplegia

dolorosa) – granulomatose inflammation in cavernous sinus, superior orbital fissure Treatment: steroid

• Gradenigo’s syndrome: otitis media inflammation of apex of petrous bone ipsilateral abducent nerve and facial pain around the ear and forehead

Facial painsHunt syndrome (ophthalmoplegia

granulomatose inflammation in cavernous sinus, superior orbital fissure –

Gradenigo’s syndrome: otitis media –inflammation of apex of petrous bone – lesion of ipsilateral abducent nerve and facial pain around

Carotid dissection• After neck trauma, extensive neck turning• Neck pain• Horner’s syndrome• Diagnosis: carotid duplex, MRI

Carotid dissectionAfter neck trauma, extensive neck turning

Diagnosis: carotid duplex, MRI-T2